Group Care Model Research Articles

Evaluating video and hybrid group consultations in general practice: mixed-methods, participatory study protocol (TOGETHER 2).

General practice is facing an unprecedented challenge in managing the consequences of the pandemic. In the midst of a policy drive to balance remote and in-person service provision, substantial workload pressures remain, together with increasing prevalence of long-term conditions, and declining staff numbers and morale. To address these challenges, some practices in the UK have been delivering video and hybrid group consultations (VHGCs) providing clinical care to multiple patients at the same time. Despite positive initial findings and enthusiasm, there are still gaps in our understanding of the influence VHGCs have on patient experience, healthcare utilisation, quality, safety, equity and affordability. To generate an in-depth understanding of VHGCs for chronic conditions in general practice, surface assumptions and sociotechnical dynamics, inform practice and extend theorisation. Mixed-methods, multi-site research study using co-design and participatory methods, from qualitative, quantitative and cost-related perspectives. WP1 includes a national, cross-sectional survey on VHGC provision across the UK. In WP2 we will engage patients and general practice staff in co-design workshops to develop VHGC models with emphasis on digital inclusion and equity. In WP3 we will carry out a mixed-methods process evaluation in up to 10 GP practices across England (5 sites already running VHGCs and 5 comparison sites). Qualitative methods will include interviews, focus groups and ethnographic observation to examine the experiences of patients, carers, clinical and non-clinical NHS staff, commissioners and policy-makers. Quantitative methods will examine the impact of VHGCs on healthcare utilisation in primary and secondary care, patient satisfaction, engagement and activation. We will also assess value for money of group and individual care models from a health economics perspective. We aim to develop transferable learning on sociotechnical change in healthcare delivery, using VHGCs as an exemplar of technology-supported innovation. Findings will also inform the design of a future study.

Evaluating video and hybrid group consultations in general practice: mixed-methods, participatory study protocol (TOGETHER 2)

Background General practice is facing an unprecedented challenge in managing the consequences of the pandemic. In the midst of a policy drive to balance remote and in-person service provision, substantial workload pressures remain, together with increasing prevalence of long-term conditions, and declining staff numbers and morale. To address these challenges, some practices in the UK have been delivering video and hybrid group consultations (VHGCs). Despite positive initial findings and enthusiasm, there are still gaps in our understanding of the influence VHGCs have on patient experience, healthcare utilisation, quality, safety, equity and affordability. Objectives To generate an in-depth understanding of VHGCs for chronic conditions in general practice, surface assumptions and sociotechnical dynamics, inform practice and extend theorisation. Methods Mixed-methods, multi-site research study using co-design and participatory methods, from qualitative, quantitative and cost-related perspectives. WP1 includes a national, cross-sectional survey on VHGC provision across the UK. In WP2 we will engage patients and general practice staff in co-design workshops to develop VHGC models with emphasis on digital inclusion and equity. In WP3 we will carry out a mixed-methods process evaluation in up to 10 GP practices across England (5 sites already running VHGCs and 5 comparison sites). Qualitative methods will include interviews, focus groups and ethnographic observation to examine the experiences of patients, carers, clinical and non-clinical NHS staff, commissioners and policy-makers. Quantitative methods will examine the impact of VHGCs on healthcare utilisation in primary and secondary care, patient satisfaction, engagement and activation. We will also assess value for money of group and individual care models from a health economics perspective. Conclusions We aim to develop transferable learning on sociotechnical change in healthcare delivery, using VHGCs as an exemplar of technology-supported innovation. Findings will also inform the design of a future study.

Perspectives of Family Medicine Providers on Nutrition of Maternal-Infant by Group Care Visits: A Cross-Sectional Study.

Group care in child welfare and primary care settings has evolved, becoming a popular approach for maternal and infant health care. This study focuses on the perspectives of family medicine providers on group care visits for maternal and infant nutrition, a crucial aspect of primary healthcare. Hence, this study aimed to explore current practices and opinions regarding the efficacy of group care models in delivering nutrition education to mother-infant dyads. A quantitative, cross-sectional study was conducted among family physicians in Buraydah, Saudi Arabia, from June to August 2023. Participants were recruited using a randomized sampling method from primary healthcare centers. Data were collected through a well-structured, self-administered questionnaire. The total participant count was 60. Statistical analyses were conducted using descriptive and inferential methods. The majority of participants were men (n=32, 53.3%), under 30 years of age (n=31, 51.7%), and had 0 to five years of experience in medical practice (n=32, 53.4%). A high weekly volume of infant and maternal clinic visits was reported (n=44, 73.3%) but predominantly conducted individual nutrition education sessions (n=60, 100%). A significant majority (n=41, 68.3%) expressed a positive potential for group care in nutrition education. The study revealed a positive inclination among family medicine providers towards group care models for maternal and infant nutrition education. However, current practices largely involved one-on-one sessions, indicating a gap between the recognition and implementation of group care models. It underscores the need for enhanced integration of group care approaches into clinical practice, highlighting their perceived benefits in efficiency and comprehensiveness. Future steps include implementing group care programs addressing participant concerns and assessing their efficacy in educating mothers on infant nutrition.

Implementation and evaluation of the centering pregnancy group prenatal care model in pregnant women with diabetes: a convergent parallel mixed methods study protocol

BackgroundDiabetes during pregnancy has negative effects on both mothers and their fetuses. To improve perinatal outcomes and women’s experience of care, the World Health Organization (WHO) suggests implementing health system interventions to enhance the use and quality of antenatal care. The main goal of this study is to implement and evaluate the outcomes of the Centering Pregnancy group care model for pregnant women with diabetes.Methods/designThe study will consist of three phases: a quantitative phase, a qualitative phase, and a mixed phase. In the quantitative phase, a randomized controlled trial will be conducted on 100 pregnant women with diabetes receiving prenatal care in Tabriz City, Iran. The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire will also be validated in this phase. The qualitative phase will use qualitative content analysis with in-depth and semi-structured individual interviews to explore pregnant women’s understanding of the impact of the Centering Pregnancy group care model on their care process. The mixed phase will focus on the degree and extent of convergence between quantitative and qualitative data.DiscussionThe implementation of the Centering Pregnancy group care approach is anticipated to empower women in effectively managing their diabetes during pregnancy, resulting in improved outcomes for both mothers and newborns. Furthermore, adopting this approach has the potential to alleviate the financial burden of diabetes on healthcare system.Trial registrationIranian Registry of Clinical Trials (IRCT): (IRCT20120718010324N80/ Date of registration: 2024-01-03). URL: https://irct.behdasht.gov.ir/trial/74206.

Adapting group care to the postpartum period using a human-centered design approach in Malawi

BackgroundResponsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi.MethodsWe completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2–4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper.ResultsAll stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period.ConclusionsUsing a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Effects of the online and offline hybrid continuous group care on maternal and infant health: a randomized controlled trial

BackgroundThe group care is a well-established maternal care model that has been widely used in many developed countries, but in China, it is confined to prenatal care services. In addition, affected by traditional birth culture, Chinese women tend to focus more on their fetuses and newborns but lack attention to their own intrapartum and postpartum care. The aim of this study was to construct and implement a prenatal, intrapartum, and the postpartum continuous group care model that combines online and offline service in Hainan Province, China, and to evaluate the effect on maternal women and newborns.MethodsThis study was a randomized controlled trial involving 144 pregnant women in a first-class tertiary general hospital in Hainan Province, China. Women were divided into an intervention group and a control group using the random number table, with 72 women in each group. The control group received routine maternal care services, and the intervention group received the continuous group care based on the routine maternal care services. Count data such as rate of cesarean section and incidence rate of fetal macrosomia were analyzed with the chi-square test or Fisher’s exact test, and the General Self-efficacy Scale scores were analyzed by repeated measures ANOVA. P < 0.05 was considered statistically significant, with two-sided probability values.ResultsCompared with the control group, the rate of excessive prenatal weight gain, cesarean section, and 42-day postpartum depression were significantly lower in the intervention group (P < 0.05), and higher General Self-efficacy Scale scores (in the expectant period and 42 days postpartum) and exclusive breastfeeding rate (42 days postpartum) (P < 0.05). The incidence of fetal macrosomia was significantly lower in the intervention group (P < 0.05). But there was no significant difference in birth weight, preterm birth, the incidence of low-birth-weight infants and 1-min Apgar score (P > 0.05).ConclusionThe continuous group care with online and offline service can effectively control the gestational weight gain, reduce the rate of cesarean section, macrosomia, and postpartum depression. It can improve the self-efficacy of women and the rate of exclusive breastfeeding effectively.Trial registrationChinese Clinical Trial Regestry (ChiCTR2200065765, 04/11/2022, Retrospectively registered).

Group vs Traditional Prenatal Care for Improving Racial Equity in Preterm Birth and Low Birthweight: The Centering and Racial Disparities Randomized Clinical Trial Study

(Abstracted from Am J Obstet Gynecol 2022;227:893.e1–893.e15 Preterm birth (PTB) is far too common in the United States and disproportionately affects Black individuals. To address these differences, a group care model was proposed that would provide health care with family and peer support and provider-led patient-centered health education.

Evaluation of implementation outcomes of an integrated group postpartum and well-child care model at clinics in Malawi

BackgroundPersistently elevated rates of maternal and infant mortality and morbidities in Malawi indicate the need for increased quality of maternal and well-child care services. The first-year postpartum sets the stage for long-term health for the childbearing parent and infant. Integrated group postpartum and well-child care may improve maternal and infant health outcomes. The purpose of this study was to examine implementation outcomes for this model of care.MethodsWe used mixed methods to examine implementation outcomes of integrated group postpartum and well-child care. We piloted sessions at three clinics in Blantyre District, Malawi. During each session we evaluated fidelity using a structured observation checklist. At the end of each session, we administered three surveys to health care workers and women participants, the Acceptability of Intervention Measure, the Intervention Appropriateness Measure, and the Feasibility of Intervention Measure. Focus groups were conducted to gain greater understanding of people’s experience with and evaluation of the model.ResultsForty-one women with their infants participated in group sessions. Nineteen health care workers across the three clinics co-facilitated group sessions, 9 midwives and 10 health surveillance assistants. Each of the 6 sessions was tested once at each clinic for a total of 18 pilot sessions. Both women and health care workers reported group postpartum and well-child care was highly acceptable, appropriate, and feasible across clinics. Fidelity to the group care model was high. During each session as part of structured observation the research team noted common health issues, the most common one among women was high blood pressure and among infants was flu-like symptoms. The most common services received within the group space was family planning and infant vaccinations. Women reported gaining knowledge from health promotion group discussions and activities. There were some challenges implementing group sessions.ConclusionWe found that clinics in Blantyre District, Malawi were able to implement group postpartum and well-child care with fidelity and that it was highly acceptable, appropriate, and feasible to women and health care workers. Due to these promising results, we recommend future research examine the effectiveness of the model on maternal and child health outcomes.

Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study

The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes. This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients. This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned. A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34). There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

Group Medical Care: A Systematic Review of Health Service Performance.

Group care models, in which patients with similar health conditions receive medical services in a shared appointment, have increasingly been adopted in a variety of health care settings. Applying the Triple Aim framework, we examined the potential of group medical care to optimize health system performance through improved patient experience, better health outcomes, and the reduced cost of health care. A systematic review of English language articles was conducted using the Cochrane Controlled Trials Register (CENTRAL), MEDLINE/PubMed, Scopus, and Embase. Studies based on data from randomized control trials (RCTs) conducted in the US and analyzed using an intent-to-treat approach to test the effect of group visits versus standard individual care on at least one Triple Aim domain were included. Thirty-one studies met the inclusion criteria. These studies focused on pregnancy (n = 9), diabetes (n = 15), and other chronic health conditions (n = 7). Compared with individual care, group visits have the potential to improve patient experience, health outcomes, and costs for a diversity of health conditions. Although findings varied between studies, no adverse effects were associated with group health care delivery in these randomized controlled trials. Group care models may contribute to quality improvements, better health outcomes, and lower costs for select health conditions.

Standardization of a Participatory Questionnaire to Assess the (Fulfilment of) Needs of Children in Care (QANCC) In India.

India has approximately 23 million children without parental care, who need alternative forms of care (MOSPI, 2018). Udayan Care, an NGO, designed an innovative group care model for children and youth in need of care and protection, implementing the indigenously developed LIFE (Living in Family Environment) strategy in 17 Udayan Ghars. (Sunshine Homes).With child participation as a core pillar, Udayan Care developed a Questionnaire to Assess the Needs of Children in Care (QANCC) in 2011, which is to be filled up by children annually, as a longitudinal study. The tool is conceived to ascertain whether children in the Ghars perceived if their rights were being fulfilled and that their needs were being addressed. With "meaningful participation" of children stipulated by the United Nations Convention on the Rights of the Child (UNCRC), the objective was to develop an evidence-based tool to assess the views of children on the services meted out to them, from their standpoint, and inform actual care practices annually. The self-assessment tool consists of questions, assessing the four dimensions of basic/fundamental, emotional, educational, and interpersonal needs, on a four-point Likert rating scale. A convenient purposive sampling is done on children, aged 10 to 18years, who receive care and protection at the Ghars, and have resided there for a minimum of 6months. This paper has two objectives, where at one end, the deductions of the previous years' data are made (2011-12 to 2016-17) with demarcating the differences with year 2018-19 data and at the second level, there is an update on the efforts made to establish the reliability and validity of the tool and create a standardized tool that can be implemented by other child care organizations in India. The paper illustrates how listening to direct voices of children and incorporating their inputs into actual care practice, can go a long way in improving the holistic wellness of children living in an alternative care setting. The results indicate that all needs of the majority of the children in Udayan Ghars.

Model fidelity of group antenatal and postnatal care: a process analysis of the first implementation of this innovative service model by the Preterm Birth Initiative-Rwanda

Background: For a large trial of the effect of group antenatal care on perinatal outcomes in Rwanda, a Technical Working Group customized the group care model for implementation in this context. This process analysis aimed to understand the degree of fidelity with which the group antenatal care model was implemented during the trial period. Methods: We used two discreet questionnaires to collect data from two groups about the fidelity with which the group antenatal care model was implemented during this trial period. Group care facilitators recorded descriptive data about each visit and self-assessed process fidelity with a series of yes/no checkboxes. Master Trainers assessed process fidelity with an 11-item tool using a 5-point scale of 0 (worst) to 4 (best). Results: We analyzed 2763 questionnaires completed by group care facilitators that documented discreet group visits among pregnant and postnatal women and 140 questionnaires completed by Master Trainers during supervision visits. Data recorded by both groups was available for 84 group care visits, and we compared these assessments by visit. Approximately 80% of all group visits were provided as intended, with respect to both objective measures (e.g. group size) and process fidelity. We did not find reliable correlations between conceptually-related items scored by Master Trainers and self-assessment data reported by group visit facilitators. Conclusions: We recommend both the continued participation of expert observers at new and existing group care sites and ongoing self-assessment by group care facilitators. Finally, we present two abbreviated assessment tools developed by a Rwanda-specific Technical Working Group that reviewed these research results.

Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

BackgroundAccess to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women’s groups suggests that group care models may both improve access to care and the quality of care delivered through women’s empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes.MethodsThe study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process.ResultsA total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1–91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics.ConclusionGroup antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system.Trial registrationClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

Model fidelity of group antenatal and postnatal care: a process analysis of the first implementation of this innovative service model by the Preterm Birth Initiative-Rwanda.

Background: For a large trial of the effect of group antenatal care on perinatal outcomes in Rwanda, a Technical Working Group customized the group care model for implementation in this context. This process analysis aimed to understand the degree of fidelity with which the group antenatal care model was implemented during the trial period. Methods: We used two discreet questionnaires to collect data from two groups about the fidelity with which the group antenatal care model was implemented during this trial period. Group care facilitators recorded descriptive data about each visit and self-assessed process fidelity with a series of yes/no checkboxes. Master Trainers assessed process fidelity with an 11-item tool using a 5-point scale of 0 (worst) to 4 (best). Results: We analyzed 2763 questionnaires completed by group care facilitators that documented discreet group visits among pregnant and postnatal women and 140 questionnaires completed by Master Trainers during supervision visits. Data recorded by both groups was available for 84 group care visits, and we compared these assessments by visit. Approximately 80% of all group visits were provided as intended, with respect to both objective measures (e.g. group size) and process fidelity. We did not find reliable correlations between conceptually-related items scored by Master Trainers and self-assessment data reported by group visit facilitators. Conclusions: We recommend both the continued participation of expert observers at new and existing group care sites and ongoing self-assessment by group care facilitators. Finally, we present two abbreviated assessment tools developed by a Rwanda-specific Technical Working Group that reviewed these research results.

Using an interprofessional prenatal group care model to address disparities in pregnancy-related outcomes in a high risk population in a family medicine residency clinic

Abstract Background Minority women are at high risk for premature births and costly complications. Prenatal care interventions may be useful for addressing these disparities. Purpose To examine whether an interprofessional prenatal group care model is superior to a matched control group receiving traditional pregnancy care in minimizing pregnancy-related disparities (e.g., low birth weight, preterm delivery, low breastfeeding initiation). Methods Quasi-experimental study including African American women (n = 64) between the ages of 18–30 from low-income households who also attended a family medicine clinic. Results Results showed that pregnant women in prenatal group care attended significantly more prenatal and postpartum visits and were less likely to be smoking at delivery compared to the matched control group. Other biological measures (e.g., preterm delivery) trended in the right direction, but did not reach statistical significance. Measures collected only in the experimental group showed significant increases in pregnancy knowledge/confidence, decreased depressive and anxiety symptoms, and high satisfaction with providers and clinic services post-intervention. In addition, women attending prenatal groups identified via focus groups that prenatal group made them feel supported, understood, and listened to, that the care was high quality because of the interprofessional providers, and the group model helped them try new health behaviors (e.g., breastfeeding, stress reduction techniques). Conclusions Future research and clinical care may want to consider utilizing interprofessional prenatal group care models. In addition, future research using a randomized controlled trial should be conducted to confirm study findings.

The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

BackgroundReducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal.MethodsThe study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation.ResultsAt baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be ‘very enjoyable’ (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers.ConclusionWhile there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal’s adapted group care model demonstrates the potential for impacting women’s antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program.Trial registrationClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

An Evaluation of CenteringParenting: A Group Well-Child Care Model in an Urban Federally Qualified Community Health Center.

Objectives: For CenteringParenting-an integrated, group participatory approach to maternal and child health-this study aimed to explore maternal participants' experiences and children's clinical metrics compared with those receiving traditional well-care visits in the same community health center. Design: A mixed-methods approach evaluated the impact of the CenteringParenting program on infant outcomes and maternal and staff experiences. Settings/Location: This study was conducted at Neighborhood Family Practice (NFP), an urban federally qualified community health center on the west side of Cleveland, Ohio. NFP is an accredited Centering Health care Institute site for both CenteringPregnancy and CenteringParenting. Subjects: Consecutive participants from the CenteringParenting program at NFP were included with age-matched controls. Outcome measures: Quantitative outcome measures included the number of well-child visits attended, immunization and lead screening rates, as well as breastfeeding initiation and duration. Semistructured interviews assessed maternal, provider, and program staff satisfaction with the program. Results: Children participating in CenteringParenting as compared with traditional individual care were demographically similar. Well-child care visits in the first 15 months of life were higher in the CenteringParenting Group (9.19 vs. 5.28, p < 0.001), which also exhibited a trend toward higher rates of completing noninfluenza immunizations. There was no difference in lead screening, with high percentages of completion in both groups. Interviews discovered strong maternal, clinician, and staff satisfaction with the program. Mothers noted the unique benefits of learning from and building relationships with each other. Conclusions: This study in a community health center indicates that innovative group care models, such as CenteringParenting, hold promise for delivering value-added elements of social interaction between parents and health care staff, in addition to increasing the number of visits attended by parents and children in the first 15 months of life. Future study is needed to further elucidate maternal, population health, and cost benefits.

Exploring Family-Medicine Providers’ Perspectives on Group Care Visits for Maternal and Infant Nutrition Education

ObjectiveExplore current maternal and infant nutrition education practices and family medicine primary care providers' views on a group care model to deliver nutrition education to mother–infant dyads. DesignIn-depth interviews. SettingFamily medicine clinics in 1 Midwestern US hospital system. ParticipantsFamily medicine primary care providers (n = 17) who regularly see infants during well-baby visits. Phenomenon of InterestCurrent maternal and infant nutrition education practices; views on ideal way to deliver nutrition education to mother–infant dyads; feedback on group care model to deliver nutrition education to mother–infant dyads. AnalysisAudio recordings transcribed verbatim and coded using conventional content analysis. ResultsFamily medicine primary care providers are limited in the ability to provide maternal and infant nutrition education and desire a different approach. Group care was the preferred method; it was shared most frequently as the ideal approach to nutrition education delivery and participants reacted favorably when presented with this model. However, there were many concerns with group care (eg, moderating difficult conversations, program implementation logistics, sufficient group volume, and interruption in patient–provider relationship). Conclusion and ImplicationsFamily medicine primary care providers desire a different approach to deliver nutrition education to mother–infant dyads in clinic. A group care model may be well-accepted among family medicine primary care providers but issues must be resolved before implementation. These results could inform future group care implementation studies and influence provider buy-in.

Our Hands, Our Health: Developing a Promising Group Healthcare Model for Pediatric to Adult Transition in a Sickle Cell Disease Clinic

Background: The transition of adolescents and emerging adults (AEA) from pediatric to adult care is often challenging. This is especially true for those with sickle cell disease (SCD) because transition coincides with a time period of rapidly increasing mortality risk. Gaps in knowledge and lack of appropriate communication skills can contribute to this risk. Many SCD AEA do not know which variant of SCD they have, cannot explain their relevant medical history, do not understand or take ownership over requesting prescription refills, and do not have the skillset to navigate health insurance. Additionally, pain is an invisible complication that cannot be objectively measured and requires communication skills. Many patients lack the necessary communication skills to effectively articulate their pain to healthcare providers. To address the transition needs of individuals with SCD, our team adapted and developed an innovative group healthcare model based on the core components of the well-established Centering® healthcare model. We produced a group healthcare curriculum entitled Our Hands, Our Health based on these gaps in knowledge. At each session, the 8-10 patients in the group will have a one-on-one visit with their hematologist and then meet with the entire group for 60 minutes of health education through group discussions led by two facilitators using interactive activities, games, and role-plays. Patients form relationships with other members of the group and with the co-facilitators as they collaboratively discuss and generate health education strategies. Methods: Using a constant comparative technique, we reviewed the core components of the Centering® model and systematically integrated these into the Our Hands, Our Heath program. The health education content reflects the needs of all AEA as well as the unique healthcare needs of AEA with sickle cell disease as they prepare to transition to adult care. Next, we completed a 6-session feasibility and acceptability study with four participants who met monthly. Then, we expanded the program from 6 to 10 sessions and conducted a full-scale pilot meeting every other month (n=13). Direct observations of sessions, debriefings, and interviews with participants and co-facilitators were used to evaluate the model. Results: Participants and co-facilitators enthusiastically embraced the Centering-based group care model. The feasibility participants (n=4) stated that they preferred group care to individual care. From the pilot, there was only one participant who did not like meeting in a group; all others (n=9) reported that they enjoyed group meetings and preferred getting their care this way. Three participants were lost to follow-up due to moving (n=2) and full-time employment (n=1). After the 4th session, six participants reported feeling more prepared for transition. Participants described the value of shared experiences and appreciated the engaging learning environment. Participants felt group meetings offered a supportive environment allowing them to develop relationships with peers who can relate, as well as with their healthcare provider, who was a co-facilitator. They were comfortable asking questions for clarification and liked being able to have in-depth discussions. Co-facilitators reported that it was more efficient to convey health education material in groups than repeating things to each patient one by one and observed participants in group care had an increased understanding of the health education messages. Some structural changes included securing a room larger, how patients were checked in and checked out, how vital signs were taken, and the hiring of a phlebotomist. Conclusions: The Centering-based group care model was feasible and acceptable by participants and co-facilitators. In addition to patient-focused assessments, we suggest including provider satisfaction and perceived quality of care measures. Sustainability is an important consideration and a costs/benefits analysis is needed. Based on our developmental research, a Centering-based group care model appears to offer a promising strategy to increase health education and will facilitate a successful transition from pediatric to adult care. Our long-term goal is to test the efficacy of such a model. DisclosuresNo relevant conflicts of interest to declare.

Where Are the Dads? A Pilot Study of a Dads-Only Session in Group Prenatal Care.

Despite suggestions that paternal engagement is one potential strategy to impact the multifaceted problem of infant mortality, fathers' involvement in prenatal care has received little attention or study. While there is evidence that fathers want information about assisting partners and caring for newborns, the best mechanism for providing this information is unknown. A pilot study was conducted using a father-only session designed to provide information in an informal, interactive setting within a model of group prenatal care. All 5 of the fathers approached agreed to participate. The fathers participating in this session indicated that the session was beneficial and found it to be a valuable addition to the group care model. Implications for health providers include identifying opportunities that allow fathers to share concerns and anxieties regarding care for partners and newborns. Implementing fathering activities into group prenatal care or developing other opportunities for fathers to be involved prenatally needs further investigation.